Every finding on record at Hospice of Greater Chicago, LLC

Upon patient record review, 2 of 19 (Patient #2,#11) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: The plan of care includes a problem of alteration in skin integrity related to a coccyx wound with interventions to assess wound. There is no evidence of documentation of wound assessments by the RN from 9/9/24 to 10/14/24. Patient 11: The plan of care includes an order for wound care to stage III pressure ulcer. There is no evidence of wound assessment documentation by the RN from 8/29 to 10/14.

Upon patient record review, 4 of 19 (Patient #2,#3,#9,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2:The medical record included nursing documentation that the care needs of the patient includes an indwelling foley catheter, dysphagia with risk of aspiration and safety risk with use of Hoyer lift. There is no evidence that the plan of care includes problems, goals and interventions for the management of the foley catheter, risk of aspiration and safety and use of a Hoyer lift. Patient 3:The medical record includes nursing documentation of bilateral nephrostomy tubes. There is no evidence that the plan of care includes problems, goals and interventions for the care and management of nephrostomy tubes. Patient 9:The medical record includes nursing documentation that the patient requires oxygen at 2-4 liters per minute via nasal cannula for shortness of breath and is at risk for aspiration. There is no evidence that the plan of care includes problems, goals and interventions for the safe use and management of oxygen or management of the risk of aspiration. Patient 13:The medial record includes nursing documentation that the patient requires Eliquis for anticoagulation therapy, has had significant weight loss of 25 lbs. in 1 month, has nausea and vomiting requiring medication management and has port-a-cath to right chest. There is no evidence that the plan of care includes problems, goals and interventions for risk of bleeding, nutrition, nausea and vomiting or the management of the port-a-cath.

Upon patient record review, 2 of 19 (Patient #2,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2:The medical record includes nursing documentation of an indwelling foley catheter and the provision of wound care. There is no evidence of an order for an indwelling foley catheter and the order for wound treatment does not include who is to perform care. Patient 14:The medical record includes nursing documentation of a wound to the left lower leg. There is no evidence that the plan of care includes an order for wound care to the left lower leg.

Upon patient record review, 2 of 19 (Patient #11,#12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 11:The medical record includes nursing documentation of a fungal rash to perineal area requiring nystatin. There is no evidence of an update to the plan of care for management of the active infection. Patient 12:The medical record includes nursing documentation of a urinary tract infection on 9/29 requiring Cipro. There is no evidence of an update to the medical record for the management of an active infection.

Upon patient record review, 2 of 19 (Patient #8,#9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 8:The patient is at risk for aspiration. The aide plan of care does not include aspiration precautions. Patient 9:The patient is at risk for aspiration and has oxygen ordered as needed for shortness of breath. The aide plan of care does not include aspiration or oxygen precautions.

Upon patient record review 3 of 19 (Patient #7,#8,#9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 7:The aide plan of care includes tasks of shower assigned 1 time per week and and bed bath 1 time per week. The aide documentation notes that the task of bed bath was provided on 9/5 and 9/6. On aide visit 9/12 both a shower and bed bath were provided. Patient 8:The aide plan of care includes task of shampoo hair assigned 1 visit per week. The aide documented that the task was completed on 9/16 and 9/18, 2 visits within the same week. Patient 9:The aide plan of care includes task of shampoo hair assigned 1 visit per week. No evidence that task was performed the week of 9/22 with all documentation noting not required this visit.

Upon patient record review, 3 of 5 (Patients #2, 3, 5) did not contain evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family's needs. The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #2: The Hospice RN documented on the 12/23/21 visit that the patient complains of dysuria. The RN called the Physician and obtained an order for a UA, which she gave to the SNF staff to follow through with. There was nothing further documented in the Hospice's clinical record regarding this area of concern until 12/28/21. On that date, a phone call was documented during which the Hospice inquired about the status of this area of concern. The SNF reported that the UA results were back, and positive for UTI. The Hospice Nurse then contacted the Physician and obtained an order for ATB, to be started that day. Patient #3: During the week of December 5-11, 2021, the Hospice RN made visits on 12/07/21 and 12/10/21.There was no documented evidence of the Hospice RN having care coordinated with the SNF nurse regarding the status of either of these wounds. Patient #5: The next SN visit, after the 12/06/21 SOC, was on 12/14/21. The Hospice Nurse documented only, "No improvement in sacral wound." It was not evident that she had care-coordinated with the SNF staff on the wound status. Additionally, there was no documentation to indicate that she had care-coordinated with the SNF staff on the shin wound status. There was no mention of the shin wound.

Upon patient record review, 2 of 5 (Patients #3 and 5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically including medications and treatments: Patient #3: The POC dated 11/13/21 included wound care orders for 3x/week and PRN. The order did not include an indication for the PRN dressing change. Patient #5: The POC dated 12/06/21 wound care orders to the sacrum BID and PRN. The order did not include an indication for the PRN dressing change. Additionally there was a wound care order for the shin. This order did not include a frequency for the wound care.

Upon patient record review 1 of 5 (Patient #2) did not contain documented evidence that a Hospice Aide had provided services that were ordered by the IDG and included in the plan of care. Patient #2: The POC ordered an Aide visit frequency of, "3x per week, effective 12/12/21." There were no Aide visits made the week of December 12-18, 2021. The week of December 19-25, 2021, there was only one Aide visit made, on 12/23/21. The same Aide POC assigned, "Partial bed-bath 1x per week, and complete bed-bath 2x per week." The week of December 26-31, 2021 the Aide made visits on the 28th, 29th, and 30th. On 12/28 the Aide documented, "Not required this visit" for both the partial bed-bath and the complete bed-bath. On 12/29 and 12/30 the Aide documented, "Patient refused" for both partial bed-bath and complete bed-bath.

Upon client record review, 3 of 4 applicable (Patient #1,2,3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1:The POC dated 12/08/21 ordered SN visits at a frequency of, "2x per week x13." There was only one SN visit documented the week of December 12-18, 2021. Patient #2:The POC dated 12/10/21 ordered SN visits at a frequency of, "1x per week x1." There were two SN visits made the week of December 5-11, 21. Patient #3: The POC wound orders dated 11/13/21, which remain current at the date of survey, include wound care to completed 3x/week and PRN - Hospice RN to provide 1x/week and SNF staff to perform on other days. During the week of December 5-11, 2021, the Hospice RN made visits on 12/07/21 and 12/10/21.There was no documented evidence of the Hospice RN having provided either the left heel nor sacral wound care at either of these visits that week.

Upon client record review, 1 of 4 applicable (Patient #5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #5: The POC dated 12/06/21 included wound care orders for the sacrum twice daily and PRN as well as wound care orders for the shin. The plan of care does not identify who is to perform this wound care (hospice nurse or facility nurse).

Upon patient record review, 4 of 13 (Patient #5,6,8,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #5 - Medication list included Morphine oral solution (20mg/ml) 5mg every 2h SL PRN. There was no evidence of an indication for the PRN. Patient #6 - The record indicated an order on the IPOC for oxygen 2-4 L/min NC PRN dyspnea. Oxygen was not included on the medication list. COS Patient #8 - The IPOC included an order for oxygen 2-4L/min NC PRN dyspnea. Oxygen was not included on the medication list. COS Patient #9- Documentation revealed in the initial nurse's note the patient was on oxygen at 3LPM via NC and on 10/28/21 the nurse's note indicated oxygen was increased to 6L/min NC. Oxygen was not included on the medication list. COS

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 4 applicable (Patient #2,5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2 - There is no evidence in the documentation of continuous assessment of the left lower leg wound which would include a dressing change and wound measurements from 9/16-11/8/21. There is no evidence of continuous assessment of the right medial heel wound to include measurements starting 11/1/21. Documentation related to the right medial heel wound said "wound tmt in place by facility wound nurse." Patient #5 - There is no evidence in the documentation of continuous assessment of the coccyx wound which would include a dressing change and wound measurements from 10/4-11/5/21.

Upon patient record review, 2 of 13 (Patient #1,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 - The record indicated the patient had a primary terminal diagnosis of stomach cancer, has had a 38 lb weight loss in 6 months and insufficient calorie intake. The plan of care did not include gastrointestinal or nutrition problems with individualized goals and interventions. Patient #5 - The record indicated the patient had a primary terminal diagnosis of senile degeneration of the brain, a FAST score of 7B, increasing time sleeping, orientated only to person and incontinence of bowel and bladder. The plan of care did not include neurological or cognitive problems with individualized goals and interventions. COS

Upon patient record review, 3 of 13 (Patient #2,5,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments Patient #2 - Documentation in the 11/1/21 nurse visit note indicated that the patient had a new right medial heel wound. The note also said "wound treatment in place by facility wound nurse." There was no evidence of a wound care order in the record. Patient #5 - The record included an order for Morphine oral soln (20mg/ml) 5mg every 2h SL PRN. There was no evidence of an indication for the PRN. Patient #9- Documentation from the initial nurse's note indicated the patient was on oxygen at 3LPM via NC and on 10/28/21 the nurse's note indicated oxygen was increased to 6L/min NC. There was no evidence of oxygen orders in the record. COS.

Upon patient record review, 2 of 9 applicable (Patient #1,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - The record included an order for the SN visit frequency to be 2x/week, but the week of 10/31/21 there is only one visit documented on 11/6/21. There was no evidence of missed visit documentation. Patient #13 - The record included a nurse visit frequency to be 2x/week. The week of 8/1/21 and 8/8/21 there was only evidence of one visit. There was no evidence of missed visit documentation.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #11) did not have evidence in the personnel file that the competency assessment was performed by the aide with a patient. The competency on file included a "v" as verbal competency.

Upon patient record review, 1 of 12 applicable (Patient #10) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #10 - The aide care plan included shave, shampoo and shower the patient 1x/week or per patient request. It also said perineal care every visit - 1x/week or per patient request.

Upon patient record review 8 of 12 applicable (Patient #2,3,4,5,6,9,12,13) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #2 - The record indicated the aide visit frequency was 3x/week. The week of 9/22/21 there were only 2 visits documented (9/22 and 9/23) and the week of 10/3/21 there was not evidence of any visits. There was no evidence of missed visit documentation. The week of 9/26/21 there were 4 aide visits documented. Patient #3 - The aide care plan included shampoo and shave weekly. The aide visit frequency was 3x/week and documentation revealed that from 9/28-11/8/21 the aide performed shampoo and shave every visit. Patient #4 - The aide care plan included shave 1x/week. The weeks of 9/26/21 (9/27 and 9/29), 10/17/21 (10/18 and 10/22), 10/24/21 (10/25 and 10/27) and 10/31/21 (11/1 and 11/5) the record indicated the aide shaved the patient 2x/week. The aide care plan said the aide was to shampoo the patient's hair weekly but the week of 10/24/21 the aide performed the task twice (10/25 and 10/27). Patient #5 - The aide care plan included shampoo 1x/week. The aide visit frequency was 3x/week. Documentation included evidence of shampoo every visit from 10/8-11/8/21. Patient #6 - The aide care plan included shampoo and complete bed bath 3x/week. Aide visit frequency was 5x/week. Documentation 9/8/21-11/9/21 aide performed shampoo and a bed bath every visit. Patient #9 - The record indicated the aide visit frequency starting 9/28/21 was 2x/week through 10/2/21 when frequency was increased to 3xweek. Documentation revealed no visits prior to 10/18/21. Week of 10/17/21 and 10/24/21 only 2 visits/week documented (10/18 and 10/20) and (10/26, 10/28) and only 1 visit documented the week of 10/31/21 (11/2). There was no evidence of missed visit reports in the record. Patient #12 - The record indicated the aide visit frequency from 6/6/21 - 7/18/21 was 3x/week. Order dated 7/19/21 to increase visit frequency to 5x/week. The week of 6/6/21 there was only 1 visit documented on 6/10/21. The week of 7/4/21 there were 4 visits documented on 7/6, 7/7, 7/8 and 7/9/21. The week of 7/11/21 there were 5 visits documented on 7/12, 7/13, 7/14, 7/15 and 7/16/21. Patient #13 - The record indicated the aide visit frequency to be 5x/week effective 7/19/21. Record included documentation of 4 aide visits the first week of service.

Upon patient record review, 1 of 13 (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #3 - The record indicated that the physician written certification of terminal illness was completed on 9/29/21 which is 6 days after the patient was admitted. There is no evidence in the record that the nurse obtained an verbal certification of illness order from the physician.

Upon patient record review, 2 of 13 (Patient #6,7) did not have evidence in the patient record that the patient/family received the Patient Notification of Hospice Non-Covered Items, Services and Drugs form when they requested it. Patient #6 - The record indicated that the POA wished to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs form. There was no evidence in the record that the form was given to the POA. Patient #7 - The record indicated that the POA wished to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs form. There was no evidence in the record that the form was given to the POA.

Upon patient record review, 5 of 13 (Patient #4,7,9,12,13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4,7,12,13 - The IPOC revealed 2 different oxygen orders. Oxygen 1-4L Nose daily PRN SOB, Oxygen 2-4L/min via NC PRN dyspnea. Patient #9 - The EOB was signed on 9/27/21. The line on the EOB that said the SOC date was blank. The EMR indicates the patient's SOC was 9/28/21 and the Program Director verified the SOC was 9/28/21. COS

Upon patient record review, 3 of 4 (Patient #3,5,9) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #3 - The record included a nurse visit frequency of 2x/week. The week of 10/10/21 there was only 1 visit documented on 10/14/21. There was no evidence of missed visit documentation in the record. Patient #5 - The record included a chaplain visit frequency of 1x/mo. There was evidence of 2 visits in the month of October on 10/5 and 10/7/21. Patient #9 - Documentation indicated the admission visit was done after midnight on 9/28/21. A return visit was made on 9/28/21 during the day. A third visit for the week was made on 9/30/21. The visit frequency for the nurse visits was 2x/week. There was no evidence of visit orders in the record for the additional visit.

Upon patient record review, 2 of 4 applicable (Patient #2,5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #2 - The record included a wound care order: cleanse left lower leg with NSS, apply xeroform and cover with dry dressing daily and prn. There was no evidence in the order if the hospice staff or the LTCF are responsible for the wound care. Patient #5 - The record included and order on the IPOC for wound care for a coccyx wound. There was no evidence in the order if the hospice staff or the LTCF are responsible for the wound care.